Protests in a Pandemic

Published Jun 11, 2020, 7:00 AM

Dr. Manisha Juthani, an infectious disease specialist and associate professor of medicine at Yale School of Medicine, provides tips for protesting safely and explains why she chose to participate.

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Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. After months of lockdown, people are beginning to come out of their houses. Many are coming out to protest. The death of George Floyd has set off demonstrations across the country. Protests in the midst of a pandemic raise unprecedented and unclear questions about both science and ethics. Crucially, they center on the question of transmission outdoors. How does the CSARS cove two virus move outdoors and how do the circumstances of protest affect that transmission. To analyze these pressing questions, we are joined today by doctor Menisha Jutani. Doctor Jutani is an Associate Professor of medicine specializing in infectious disease at the Yale School of Medicine. She's also an attending physician at the Yale New Haven Hospital, where she's been instrumental in leading the infectious disease efforts. Addressing COVID nineteen Minsha, thank you so much for being here. You've been following the question of how the stars covy two virus spreads very closely, and then in the middle of the scientific effort to make sense of this very very important question, we suddenly were faced with the protests about the death of George Floyd, and we're in a completely new universe where the question of transmission is being filtered through a new form of social interaction that it hadn't occurred on this scale previously. It's sort of like an advanced course transmission with ethical dimensions as well as scientific dimensions. I want to start by asking you about the scientific dimension. What do we know about outdoor transmission of this virus? To begin with, science on outdoor transmission is still evolving. What we know so far is that in series of outbreaks that have been identified from China to start and other areas of the world, including Japan, it appears that most transmission is occurring indoors, when people are face to face and spending more than ten minutes of time, let's say, talking to each other. This is the highest risk of exposure. Now, what we've seen happen is that families and the household setting is probably the number one way that this virus is transmitted. Part of that is because that's where people have been stuck. People who got infected were at home and they were with each other, and so they went on to infect each other. And people buy and large have not been wearing masks in their own homes. The next way that we saw that this virus was transmitted, probably in highest proportion, is in transportation settings. Again, this makes sense that people are on a train for prolonged period of time. Let's say you're taking an hour ride from the suburbs of New York City into New York City or Boston or other big cities of the like. If you're in a setting where you are with a group of people for a prolonged period of time, potentially sitting side by side, face to face, maybe you cough, maybe you're talking on your phone, and the person next to you is getting that transmission of virus that This is the second, probably most common way people have been infected. So getting to the outdoors. Outdoors has been the lowest risk identified mechanism of transmission. So in one series that was looked at, there was only one person that was clearly identified to risk of outdoor transmission. Most transmission events that have been able to be tracked have been to some sort of indoor setting, which gives us additional confidence that the outdoors is likely a much lower risk place where people can get COVID nineteen. I was very affected by the Wuhan study that you were just describing, where by my reading of the study and correct me if I get it wrong. They looked at seventy five hundred individual cases, and only one of those cases could they show definitively had been transmitted outdoors. I had recognized it's only one study. I recognize it was the winter, and that most people also may have been under lockdown, so that may be the reason it was such a small number. I did have an instinctive reaction to that, thinking, wow, it must be pretty difficult to transmit the virus outdoors. Why what is it about being outdoors that has this effect? I mean, the most obvious thing to me is a layers and is there's a whole lot of air outdoors. I think there are several factors. Number One, most of the time when people are outdoors, they tend to be further apart from each other. Not always. There are certain contexts like the recent rallies and protests, when people are in closer proximity to each other. However, a lot of times if people are even if they are going to public pools or they are going in a park or they're watching an outdoor concert, they tend to be a little bit further apart. Secondly, as you mentioned, the air is blowing, and that may be part of the reason that this infection cannot perpetuate as much in the outdoor setting. People have postulated that while maybe win could make it worse, that you have aerosols that are in the air and it can blow from one person on the end of a field to another person on the other end of the field. Although in theory that is possible, I think from what we've seen so far, I suspect that the science will be able to show us over time that droplets that are generated through coughing or talking or singing, or all the activities that we know through human projection of voice that occur that win an air and just sort of the natural barriers that come, whether it bay trees or leaves or benches or other things that get in the way of these droplets along the way, maybe more likely to break up those droplets and make the particles less likely infectious or non infectious at all. Turning to the protests, What were the circumstantial events or what have been so far that would potentially change this calculus, again on the scientific not the ethical level. So if your tear gased, is that likely to cause you to aerosolize? I mean, you cry, you cough, maybe you sneeze. I don't think crying is an aerosolizing event, but the others are right. Certainly the coughing, chanting, screaming, talking, loudly, singing, these are all very clearly aerosol generating events. Now, I would say there's some protests I've seen where people are not wearing masks, but by and large I have visualized even firsthand, is that almost everybody is wearing a mask, and that is certainly good. However, the thing that we don't know is that the outdoor data that has been collected so far, at least in the one case that you described in that study that we talked about again, was a person talking face to face with somebody else. If we have a setting where there are a lot of people who are together and you have multiple aerosol generating events happening all at once, will the risk go up? We just don't know the answer to that. We are living in a real life, real time natural experiment. That is what's going on right now, and only the facts are going to show us what happens. And I don't think it's necessarily in the next week or two, because in my calculus, in the next couple of weeks, it might be that some people will have asymptomatic infection, that some people will have mild cases of infection, may or may not go to get tested, but it depends what they go and do after that. Are they going back to individual units where if they did get infected, potentially they're staying quarantining or not engaging as much in public life as maybe they were months ago, And if they did get infected, maybe that'll be the end and that'll self terminate the cascade of infection versus people who are going home to maybe multigenerational homes where a month from now, not just a week or two from now, but a month from now, we now see people who are older and debilitated or have multiple other chronic conditions now coming to the hospital and getting a spike in hospitalizations at that point. So I think that's what we are living with and we just have to wait and see what happens. Now you set something that actually makes me think the science is going to be a lot harder than I had originally imagine it would be, for the following reason. If we could see a result in two weeks, let's say, then I think a good statistician looking at national data and matching where people live to where there were protests of different sizes, could begin to draw an association and interpret the natural experiment that you describe. But if it's going to take a month, I'm concerned that there's going to be the possibility again, just from an analytic perspective, of a conflation between the fact of the protests and the fact that so many places across the United States are gradually opening up and began to do so at almost exactly the same time that the protests began, namely the very end of May and the beginning of June. And if that's the case, maybe a very very skilled statistician could begin to pluck out data from the noise. But it actually sounds to me like it's going to be really hard to do if it's going to take a month. That is my exact same concern. I have a feeling that it's going to be very very difficult to sort that out when you're looking at broad strokes. What you could do is look at specific, smaller subsets of the population and smaller groups. One thought I've had, for example, is that there are many physicians that have also been protesting. On Friday, there was a large movement for white coats for Black Lives, and there were many physicians who were out there. Now, if these physicians have been using Personal Protective Equipment PPE in the hospital, and we've seen that when you use PPE, the risk of transmission is quite low. In fact, we know that the PPE works. That's what our first experiment has shown us that in fact, we can be protected as healthcare providers if we use it. So the question is if these people are used masks in protests, if they are using PPE in the hospital, and maybe are re engaging in society a little bit. With some of the loosening of restrictions that have happened in certain areas, you might be able to say, well, okay, if these people are getting screened and tested maybe on a more regular basis, because that's also part of what we're doing. Do we see associations with people who went to a protest versus those who did not. That's a very defined group of people where maybe you might be able to get at that question. But if we just look at sort of the epidemiologic way that we might look at some of these questions, I think exactly what you highlighted is going to be very difficult to tease out. So there's the potential for challenge in that. I like your experiment idea to look at medical professionals who went to the protest, but I can immediately think of a confound which is that they're going to be disproportionately likely to use PPE correctly and to maintain social distance at the protest tests because they are medical professionals. So you might be able to make a comparison between them and other medical professionals, but that won't necessarily give you any external validity for trying to figure out what that means for the rest of us. When we went to the protests, I totally agree, and I'll speak as a protester myself. I stood on the way periphery and I did not go near chanting crowds myself because I felt that that was a safer way given what I know, without having to necessarily be right in the middle of the protest. We'll be back in a moment. So I'm fascinated when you talk about your own experience at the protests that, notwithstanding your very clear analysis that the data suggests that risks of transmission outdoor are actually arguably pretty low, that nevertheless, were concerned enough about chanting and singing to stay on the periphery and to avoid loudly chanting protesters. And I want to ask you, I guess a personal question. Is that because you on the whole or a person who likes to make assurance double shore and be safe, or was that your assessment that rationally speaking, everybody in the crowd actually should have not chanted very loudly and not sung and stated a greater distance from each other. Did you have an instinct to want to warn everybody else about this too, Yes, I did have an instinct to want to do that. But I know also that people are entitled to their right to do what they feel is appropriate in the moment in time that we're in. And I'm not going to deny that I would have liked to participate in that way myself, but as a public health measure for myself if I am asymptomatically infected, I didn't want to put others at risk. And so there is a way to show civil disobedience and to show protests even in silence, and I felt that I was able to do that in a way that was comfortable for me. But I also understand people are in a very difficult position right now and are entitled to do what they feel is right for them. But I have encouraged people to try to maintain distance, not scream, shout, or saying or chant, as a way to protect themselves and protect others because I do fundamentally believe that the outdoors is so much safer than anything indoors, So protesting outside I think can be done in a low risk environment. I cannot say that it's no risk. I tell people all the time, if you're a very anxious person and you are worried about risk, you should just stay home and stay indoors. However, if you are trying to engage in a way that feels comfortable to you and in a way that at the moment we think is the safest what I've described, which is to try to exhibit silence, wear a mask, keep distance, and still protest. That is what I would advocate for. I think that people will be seen and heard even in silence. One of the really complex ethical issues that you've already alluded to, but I want to ask you more about, is the question of medical professionals white coats protesting in their white coats. White coats for black lives is sometimes the slogan that's used, and that's raised an ethical question about the consequences not just for them, but for everybody of engaging in protest in a situation where there is at least a possibility of transmission. Karl Bergstrom, the epidemiologist and statistician whom we've had on the show, has been posting, not without a lot of opposition, on Twitter, that he wants to remind people that you're not only carrying risk for yourself in a situation of epidemic, but you're actually imposing an externality. You're creating a risk for other people if you're engaged in risky behavior with respect to transmission. How do you think about that concern? In healthcare, there has been systemic racism for a long time. I've spoken to students, residents, fellows, attending physicians who have experienced racism in their careers for decades as a South Asian American, as a woman of Indian descent, I've had many comments myself. I've been called Gandhi as a young person in a mall on nine to eleven. My husband, who's also of Indian descent. We lived in New York City and our doorman, who saw us every single day, wouldn't allow him in the building and told us to go back to where we came from. I believe that as a healthcare professional to stand up for patience and providers that have experienced this kind of racism in their lives, and as a medical educator to say, if I'm a bystander and see something that's wrong, I'm not going to stand for it, and I'm going to stand up for somebody who maybe is having a hard time speaking on behalf of themselves. I want to make a point to say that I will do that, and I'm going to stand on the side of what I think is right. And this is a critical juncture in our country. And as much as I'm on the side of protecting people from COVID nineteen, there is a confluence of events that is happening right now and we have to recognize what is going on. And so I have struggled with this myself. As you mentioned, how can I go about and express what I think is an equally important message to get out there at the same time as trying to prevent a potential huge second wave. The way that I see that being able to happen is I went to one protest. I went in my white coat. I showed people around them that should something happen, I am a white coat. I am ready to help those that might be in need. But I'm going to stay on the periphery because that's what I'm comfortable with. I don't want to put other people at risk, and I don't want to be at risk because I need to keep doing my job. I need to continue being able to be a physician taking care of patients, and continue being an educator, educating trainees and educating the public. So I think there is a conflict here, but at the end of the day, we all are human beings and we all have to stand on the side of what we think is right. In this moment, when I hear the phrase systemic racism in the context of health outcomes, I tend to think of the long range consequences of slavery and segregation in the United States and economic inequality, primarily for African Americans, and the consequences that that has had for the health of African American people. And the COVID nineteen epidemic is a perfect instantiation of this, and that's the reason that African Americans seem to be around three times more likely to die of COVID than white people. That's a question of the effects of that kind of systemic racism. And so I think for those who have expressed trepidation around the protests, one of the things that they've been saying is African Americans might be disproportionately likely to be protesting in Black Lives Matter, and African Americans are disproportionately likely to be contracting and becoming ill from the disease. And here, I guess what I'm wondering is is it your instinct that the risk of transmission aren't so great in protests as to make this as pressing a dilemma as some people would like to make it out to be. I think that's a difficult call on a question. And the reason I say that is because I'm extremely concerned about outbreaks to come, particularly in communities where the current prevalence of infection is still high and rising. So there are many communities where protests are happening where the incidence of infection is quite low or getting even lower, and so I'm less concerned in those communities, but still extremely concerned. But I also fully respect the need to protest right now, and everybody has to take the risks that they think are appropriate for them. But from my vantage point, if you wear a mask, if you try to prevent touching your face, if you watch your and try to protect yourself and others by not screaming, shouting, or yelling while maintaining distance, I think you can still have an equally effective protest. And I know that that is hard to do. I know what I'm asking for is almost impossible, and that maybe I'll convince a few others to protest in that way, but that the majority of people won't want to do that, And I understand that, and I respect that decision, but I do feel that the risk that you're potentially putting others too, and you yourself are putting yourself at is potentially significant. I fully acknowledge that the outdoors is better, But we don't have the science of riots and protests to say that we can extrapolate the data we have so far to these settings. I don't think is accurate, and so I think as an infectious disease doctor, as an epidemiologist, I'm going to be on the side of cause I'm going to be on the side of putting into place the measures that can most likely result in the least number of infections, not no infections. I'm not expecting that, I'm just expecting to reduce the number. Fast forward a month. Imagine, just for the sake of argument, that we haven't seen a substantial spike in cases correlated in any way, shape or form with the locations of protests. Imagine a best case scenario. Would you then think that it would be plausible for public health officials to say, Okay, it's the summer, the beach is really pretty safe because it's not as extreme as a protest, and there's no tear gas there, and pools are outdoors and therefore reduced transmissions substantially, and outdoor restaurants should be opened, and we should basically treat the summer while we can as before the fall comes and we are all indoors in high transmission environments, again as an opportunity to get out there and live a little bit of life. Can you imagine a scenario like that, and if the data doesn't spike by then, do you think you would be comfortable making recommendations like that. I think I might. I think you know, I'd like to see where we go. But I think in an ideal best case scenario, if that's the case, I think I would listen to your local public health officials and governors and people making regulations for your local districts because every area is going to be a little bit different, and the nuance and reasoning in different areas are going to be different. But for me personally, if we see that, I'll feel even better about what I recommend people to do in terms of the outdoors. But again, what I've seen is that most of these places people have been wearing masks. So if you're going to be up close and personal with somebody, I'm not going to tell you to take your mask off. I'm going to say keep your mouth gone, which is hard in the summer and being outdoors and all that. But if you're on the beach, and you're spread out and you have your mask off and you're not necessarily getting all on top of other people. I will absolutely feel comfort with that. I think I would say again, it's not a no risk situation, it's an extremely low risk situation. I hope that we end up there. I really do, because I am concerned about December January February, our typical flu season spike, and to have the mental health of the American people be in a place where they're ready for our next typical flu season, to have had time where they got outside and reengaged with friends and family and had some time to be able to maybe reduce the anxiety, fear, and preoccupation with getting infected. It would be a great way to give people a little bit of a release before going into the next season. But I think, as you've kind of alluded to, none of these things are going to be all or none, light on, light off. It's going to be Can we phase a little bit in the direction of loosening things up and enjoying what we can while we can in the summer, and then potentially locking down, clamping down a little bit more when it's going to be cold and people are going to be stuck inside, and that's when disease transmission usually we would anticipate is going to be higher. Anyway, thank you Manasa so much for this detailed analysis of the science and ethics of transmission and protesting, and thanks for your amazing work, and thanks for joining me. Thank you so much for having me listening to doctor Jutani's a very cogent analysis. I think there are a few pretty straightforward takeaways. One, at least as we know from the data, transmission of the virus outdoors seems to be extremely unusual. Two, that same body of data can not yet be safely extrapolated to the circumstances of a protest, because that data was collected in winter in China, under circumstances where many people were in lockdown, and when there were not protests, with people singing, chanting, coughing, and engaging in other aerosolizing events potentially in proximity to each other. Third, the difficult ethical question of whether protest is appropriate under circumstances of pandemic is very much inflected by an empirical prediction without knowledge of exact science about how likely it is for the disease to spread. And I thought that Menetia was particularly insightful when describing her own decision to go out in protest, but to do it from the periphery of the crowd and to avoid chanting and singing. Fourth and last, in a month or so, we may actually have some preliminary sense of new science about what mission looks like under circumstances of protest. And maybe, just maybe, if we're lucky and we don't see significant disease spike in the next month, it might be possible over the summer for us to conclude that spending time outdoors, albeit with masks, places us in relatively low risk of transmission. But it's too soon to know that. We won't know that till sometime around the July fourth weekend. We will continue to follow closely the question of how the virus spreads and what is safe for people to do outdoors over the course of the summer. Until the next time I speak to you, Be careful, be safe, and be well. Deep background is brought to you by Pushkin Industries. Our producer is Lydia Jane Cott, with research help from zoo Win and mastering by Jason Gambrel and Martin Gonzalez. Our showrunner is Sophie mckibbon. Our theme music is composed by Luis Guerra. Special thanks to the Pushkin Brass, Malcolm Gladwell, Jacob Weisberg, and Mia Lobel. I'm Noah Feldman. I also write a regular column for Bloomberg Opinion, which you can find at Bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash podcasts. And one last thing, I just wrote a book called The Arab Winter, The Tragedy. I would be delighted if you checked it out. You can always let me know what you think on Twitter about this episode, or the book or anything else. My handle is Noah R. Feldman. This is deep background

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